Screening coronary artery disease with computed tomography angiogram should limit normal invasive coronary angiogram, regardless of pretest probability.

BACKGOUND: Performing functional testing (FT) or a computed tomography angiogram (CCTA) before invasive coronary angiogram (ICA) is recommended for coronary artery disease (CAD). We aimed to evaluate, in a real life setting, the rate of strictly normal ICA following a positive noninvasive test result. METHODS: We included all patients who underwent an ICA with a prior positive FT or CCTA. Patients were categorized in 5 subgroups, according to pretest probability (PTP) of having a CAD. Main results of ICA were defined as normal ICA, nonobstructive CAD (non-oCAD), and obstructive CAD (oCAD). RESULTS: For 4,952 patients who underwent ICA following either a positive FT (3276, 66.2%) or CCTA (1676, 33.8%) result, the PTP was (1) low (<15%; n = 968, 19.5%), (2) lower intermediate (15%-35%; n = 1336, 27.0%), (3) higher intermediate (35%-50%; n = 806, 16.3%), (4) high (50%-65%; n = 806, 17.7%), and (5) very high (> 65%; n = 965, 19.5%). ICA showed no CAD (819 patients, 16.5%), non-oCAD (1,193 patients, 24.1%), or oCAD (2940 patients, 59.4%). Without considering the PTP values, CCTA compared to FT showed less frequently normal ICA (7% vs 16.5%), and more frequently CAD (non-oCAD 27.9% vs 22.2%; oCAD 65.1% vs 56.4%) (all P < .0001). When we considered the different PTP values, CCTA always showed lower rates of normal ICA than the FT. In low- and lower intermediate-risk patients, CCTA detected more frequently oCAD compared to FT (P < .001). CONCLUSIONS: CCTA is a better alternative than FT to limit unnecessary ICA regardless of PTP value, without missing abnormal ICA.

How to limit radial artery spasm during percutaneous coronary interventions: The spasmolytic agents to avoid spasm during transradial percutaneous coronary interventions (SPASM3) study.

AIMS: To compare the efficacy of three vasodilators in preventing radial artery spasm (RAS) in patients undergoing transradial percutaneous coronary interventions (PCI). METHODS AND RESULTS: 731 patients were randomized to receive diltiazem 5 mg, verapamil 2.5 mg, or isosorbide dinitrate (ISDN) 1 mg before coronary intervention. RAS occurred in 20.1% in the whole population and was significantly reduced by verapamil and ISDN compared to diltiazem (16.2, 17.2, and 26.6%, respectively; P < 0.006). There was also a trend towards less severe pain (more than 8 on a numerical scale from 0 [no pain] to 10 [maximal pain]), and less severe RAS (complete catheter blockage or severe pain), among patients treated by verapamil compared to ISDN and diltiazem (1.3% vs. 2.8% vs. 2.9%, P = 0.43 and 5.1% vs. 6.2% vs. 9.5%, respectively, P = 0.13). No difference was found between the three vasodilators in terms of crossover or safety events. Female gender, failure at first attempt to access the radial artery, emergency procedures, and the use of diltiazem were independent predictors of RAS. CONCLUSION: Verapamil and ISDN considerably reduce the incidence of RAS compared to diltiazem during transradial PCI.

Unicuspid aortic valve by cardiac computed tomography: the best view is from the mountaintop-a case report.

Background: Unicuspid aortic valve (UAV) is a rare valvular heart disease and a challenging diagnosis. Advanced imaging techniques, particularly cardiac computed tomography (CT), appear to be invaluable tools to correctly identify this disease pre-operatively, as this may have an impact on the optimal surgical treatment. Case summary: We describe the case of a young patient admitted with heart failure, due to a severely stenotic UAV. Cardiac CT allowed adjusting the imaging plane to the best view in two orthogonal planes to identify the top of the 'dome' and to accurately measure the smallest valve opening by planimetry. Surgical inspection confirmed a rare case of acommissural UAV. Discussion: Cardiac CT angiography is crucial to understand the complexity of UAV disease and to differentiate the acommissural from the unicommissural type. Accurate positioning of the imaging plane through the smallest valve opening in systole reduces the risk of missing the diagnosis of this rare disease.

Double Culprit Lesions in a Patient With ST-Segment Elevation Myocardial Infarction: Should I Stent or Should I Go?

We describe the case of simultaneous acute thrombotic occlusions in 2 major coronary arteries in a young patient admitted for extensive myocardial infarction. We highlight the importance of intravascular imaging to determine the underlying putative mechanism and to optimize treatment decisions. (Level of Difficulty: Intermediate.).

Smart bracelet to assess physical activity after cardiac surgery: A prospective study.

OBJECTIVES: Little is known about the physical activity of patients after cardiac surgery. This study was designed to assess this activity using a connected bracelet. METHODS: In this prospective, monocentric study, patients scheduled for cardiac surgery were offered to wear an electronic bracelet. The main objective was to measure the physical activity recovery. Secondary objectives were the predictors of the correct use of the monitoring system, of the physical recovery and, if any, the relationship between physical activity and out-of-hospital morbidity. RESULTS: One hundred patients were included. Most patients (86%) were interested in participating in the study. The compliance to the device and to the study protocol was good (94%). At discharge, the mean number of daily steps was 1454 ± 145 steps, increasing quite homogeneously, reaching 5801±1151 steps at Day 60. The best fit regression curve gave a maximum number of steps at 5897±119 (r2 = 0.97). The 85% level of activity was achieved at Day 30±3. No predictor of noncompliance was found. At discharge, age was independently associated with a lower number of daily steps (p <0.001). At Day 60, age, peripheral arterial disease and cardio-pulmonary bypass duration were independently associated with a lower number of daily steps (p = 0.039, p = 0.041 and p = 0.033, respectively). CONCLUSIONS: After cardiac surgery, wearing a smart bracelet recording daily steps is simple, well tolerated and suitable for measuring physical activity. Standard patients achieved around 6000 daily steps 2 months after discharge. 85% of this activity is reached in the first month. CLINICAL TRIAL REGISTRY NUMBER: NCT03113565.

Stent thrombosis after primary percutaneous coronary intervention in comatose survivors of out-of-hospital cardiac arrest: Are the new P2Y12 inhibitors really more effective than clopidogrel?

AIM: High rates of stent thrombosis (ST) have been reported in patients with out-of-hospital cardiac arrest (OHCA) who require a primary percutaneous coronary intervention (PCI). The aim of this study was to assess risk factors of ST in this population with a special focus on antiplatelet therapy administered during the acute phase. MATERIALS AND METHODS: We conducted a retrospective observational study in patients treated with primary PCI after OHCA between 2011 and 2013 in our center. All consecutive patients were treated with mild therapeutic hypothermia and dual antiplatelet therapy after primary angioplasty. RESULTS: A total of 101 consecutive patients were included in the present analysis. Mean age was 61.3 ± 12.7 years and 75% of patients had an initial ventricular fibrillation. All patients received aspirin before PCI. P2Y12 inhibitors were administered after PCI and included clopidogrel (47.5%), prasugrel (21.8%) or ticagrelor (29.7%). The survival rate at discharge was 44.5%. We identified 11 cases (10.9%) of definite or probable ST (clopidogrel (n=2), prasugrel (n=4) and ticagrelor (n=5)) occurring at a median of 2 days after PCI. No specific predictors were found to be significantly associated with ST. New P2Y12 inhibitors were associated with more ST compared to clopidogrel (17.3% vs. 4.2%; respectively, p=0.05). ST was associated with a decreased left ventricular ejection fraction (p=0.007) and with a trend toward a higher mortality compared to patients without ST (82% vs. 52%, p=0.06). CONCLUSION: The incidence of ST in OHCA survivors is high and associated with poor clinical outcome. The use of new oral P2Y12 inhibitors does not appear to be associated with a reduction in ST compared to clopidogrel.

Emergency Percutaneous Coronary Intervention in Post-Cardiac Arrest Patients Without ST-Segment Elevation Pattern: Insights From the PROCAT II Registry.

OBJECTIVES: In a large cohort of out-of-hospital cardiac arrest (OHCA) patients without ST-segment elevation (STE), the study assessed the relationship between the use of an early invasive strategy and patient outcome. BACKGROUND: Emergent coronary angiogram (CAG) and reperfusion are currently a standard of care in patients resuscitated from an OHCA with ST-segment elevation (STE). However, using a similar invasive strategy is still debated in patients without STE. METHODS: In the absence of an obvious extracardiac cause, for many years our practice has had to perform an emergent CAG in all OHCA patients (STE and no STE) at admission, followed by percutaneous coronary intervention (PCI) when required. All patients' characteristics are prospectively collected in the PROCAT (Parisian Registry Out-of-Hospital Cardiac Arrest) database. Focusing on non-STE patients and using logistical regression, we investigated the association between early PCI and favorable outcome (cerebral performance category 1 to 2 at discharge) and we searched predictive factors for PCI requirement. RESULTS: During the study period (2004 to 2013), we investigated 958 OHCA patients with an emergent CAG. Among them 695 of 958 (73%), mostly male (76%), and average 60 years of age had no evidence of STE on the post-resuscitation electrocardiography. A PCI was deemed necessary in 199 of 695 (29%). A favorable outcome was observed in 87 of 200 (43%) in patients with PCI compared with 164 of 495 (33%) in patients without PCI (p = 0.02). After adjustment, PCI was associated with a better outcome (adjusted odds ratio: 1.80 [95% confidence interval: 1.09 to 2.97]; p = 0.02). The other predictive factors of favorable outcome were a shorter resuscitation length (<20 min), an initial shockable rhythm, and a lower dose of epinephrine during resuscitation (p < 0.001). An initial shockable rhythm (adjusted odds ratio: 2.83 [95% confidence interval: 1.84 to 4.36]; p < 0.001) was the sole independent indicator for PCI requirement. CONCLUSIONS: A culprit coronary lesion requiring PCI was found in nearly one-third of OHCA patients without STE. In these patients, emergent PCI was associated with a nearly 2-fold increase in the rate of favorable outcome. These findings support the use of an invasive strategy in these patients, particularly in those resuscitated from a shockable rhythm.

Stent thrombosis: an increased adverse event after angioplasty following resuscitated cardiac arrest.

BACKGROUND: The leading cause of sudden cardiac death is myocardial ischemia. As for uncomplicated acute myocardial infarction (AMI), international guidelines plead for early coronary angiography with, in case of culprit lesion, angioplasty and stent implantation. However after cardiac arrest (CA), shock, hypothermia and changes in antiplatelet pharmacokinetic may promote stent thrombosis (ST). Incidence of ST in this situation has never been studied. OBJECTIVE: The aim of this study was to investigate incidence and determinants of ST after ischemic CA successfully revascularized. METHODS: We analyzed 208 consecutive patients admitted in our institution for AMI and who underwent PCI with stent implantation. Among these patients, 55 presented a resuscitated CA and were compared to 153 without CA (control group). All patients in the CA group received hypothermia (33 °C for 24 h) following resuscitation and PCI. RESULTS: There was no difference between the 2 groups for age, gender, cardiovascular risk factors, coronary lesions and type of stent. In the CA group, patients were less frequently pre-treated with heparin (50.9% vs 98.7%, p<0.001) and aspirin (52.7% vs 99%, p<0.001). In the CA group, we observed a significantly higher incidence of confirmed acute or subacute ST than in the control group: 10.9% vs 2.0% (p=0.01). None of CA patients had received a dual antiplatelets therapy (0% vs 99%). LVEF at admission was lower in the CA group (40.3% vs 48%; p<0.001), and shock was more frequent (83.6% vs 8.5%; p<0.001). Survival at 28 days was 50.1% in CA group vs 98.0% (p<0.001). In multivariate analysis, CA before stenting appears to be an independent risk factor for confirmed ST (OR=12.9; 95%CI 1.3-124.6; p=0.027). CONCLUSION: In CA patients treated with cooling, stenting for AMI is associated with a high risk of ST. Shock, insufficient antithrombotic treatment, pharmacokinetic changes related to hypothermia may contribute to this higher risk. A strategy aiming to reduce this complication may probably improve prognosis of patients who underwent coronary sudden death.

Is epinephrine during cardiac arrest associated with worse outcomes in resuscitated patients?

BACKGROUND: Although epinephrine is essential for successful return of spontaneous circulation (ROSC), the influence of this drug on recovery during the post-cardiac arrest phase is debatable. OBJECTIVES: This study sought to investigate the relationship between pre-hospital use of epinephrine and functional survival among patients with out-of-hospital cardiac arrest (OHCA) who achieved successful ROSC. METHODS: We included all patients with OHCA who achieved successful ROSC admitted to a cardiac arrest center from January 2000 to August 2012. Use of epinephrine was coded as yes/no and by dose (none, 1 mg, 2 to 5 mg, >5 mg). A favorable discharge outcome was coded using a Cerebral Performance Category 1 or 2. Analyses incorporated multivariable logistic regression, propensity scoring, and matching methods. RESULTS: Of the 1,556 eligible patients, 1,134 (73%) received epinephrine; 194 (17%) of these patients had a good outcome versus 255 of 422 patients (63%) in the nontreated group (p < 0.001). This adverse association of epinephrine was observed regardless of length of resuscitation or in-hospital interventions performed. Compared with patients who did not receive epinephrine, the adjusted odds ratio of intact survival was 0.48 (95% confidence interval [CI]: 0.27 to 0.84) for 1 mg of epinephrine, 0.30 (95% CI: 0.20 to 0.47) for 2 to 5 mg of epinephrine, and 0.23 (95% CI: 0.14 to 0.37) for >5 mg of epinephrine. Delayed administration of epinephrine was associated with worse outcome. CONCLUSIONS: In this large cohort of patients who achieved ROSC, pre-hospital use of epinephrine was consistently associated with a lower chance of survival, an association that showed a dose effect and persisted despite post-resuscitation interventions. These findings suggest that additional studies to determine if and how epinephrine may provide long-term functional survival benefit are needed.

Update on the need for a permanent pacemaker after transcatheter aortic valve implantation using the CoreValve® Accutrak™ system.

AIMS: High rates of permanent pacemaker (PPM) implantation are reported after transcatheter aortic valve implantation (TAVI) using the Medtronic CoreValve® system. The Accutrak™ catheter is designed to allow a more predictable landing zone. Little is known about the real clinical impact of this catheter. The aims of this paper were to describe the potential impact of the Accutrak™ catheter on the accuracy of positioning a 26 or 29 mm CoreValve® across the aortic annulus and its impact on the need for a pacemaker. METHODS AND RESULTS: A total of 134 patients were treated with the CoreValve® Accutrak™ system at two French centres (Lille and Toulouse). Mean age was 82.4 ± 4.7 years; logistic EuroSCORE was 24.3 ± 9.5%. Procedural success rate was 99.2%; mean depth of implantation was 4.9 mm. A final position between 0 and 6 mm was achieved in 85.8% of the patients. All-cause mortality at 30 days was 6%. The PPM implantation rate was 10.6%. Due to a limited number of events, we could not identify any predictor of need for a PPM: pre-existing right bundle branch block (RBBB) (OR 2.72 [0.63-11.87], p=ns), use of a 29 mm prosthesis (OR 2.73 [0.33-22.90], p=ns) and left ventricular septal hypertrophy (OR 2.63 [0.08-83.32], p=ns). CONCLUSIONS: In this cohort of patients treated with the CoreValve® Accutrak™ system, the incidence of permanent pacemaker implantation was low, which may be a consequence of an average small implantation depth. The Accutrak™ catheter seems to be helpful in achieving higher and more predictable implants. Operators could standardise their technique to place the CoreValve® prostheses less than 6 mm below the aortic annulus.

A simple nomogram for early prediction of myocardial reperfusion after pre-hospital thrombolysis.

AIMS: To discriminate early ST-segment elevation myocardial infarction (STEMI) presenters at a high probability of successful pre-hospital thrombolysis (PHT) using a simple nomogram based on independent predictors of complete ST resolution. METHODS AND RESULTS: OPTIMAL was an observational, prospective study undertaken at 79 medical centres in France in patients with STEMI undergoing pre-hospital thrombolysis (PHT) within six hours of symptom onset and coronary angiography within six hours of thrombolysis. The baseline and pre-coronary angiography ECGs of 800 patients were analysed. The main outcome measure was ST segment resolution ≥ 70%. ST resolution was associated with a significant reduction in mortality (1.8% vs. 4.3%; p=0.05). After multivariable logistic regression analysis, five independent predictors of successful myocardial reperfusion were identified: ≤ 1 h between pain onset and thrombolysis (odds ratio [OR] 1.76, 95% confidence interval [CI] 1.18-2.62); body mass index (BMI) <30 kg/m2 (OR 1.74, CI 1.12-2.72); current/previous smoking (OR 1.71, CI 1.21-2.43); non-anterior infarct territory (OR 1.75, CI 1.27-2.41); and maximum amplitude of ST elevation <3 mm (OR 1.83, CI 1.32-2.54). The C-statistic of the model was 0.71 (95% CI 0.67-0.74). Using these five independent factors, a simple nomogram was developed to assess the probability of ST resolution after PHT. This nomogram allows discrimination of probabilities ranging from 13 to 72%. CONCLUSIONS: This simple nomogram can predict the probability of successful myocardial reperfusion after thrombolysis. This may be useful in the triage of STEMI presenters.

Immediate percutaneous coronary intervention is associated with better survival after out-of-hospital cardiac arrest: insights from the PROCAT (Parisian Region Out of hospital Cardiac ArresT) registry.

BACKGROUND: Acute coronary occlusion is the leading cause of cardiac arrest. Because of limited data, the indications and timing of coronary angiography and angioplasty in patients with out-of-hospital cardiac arrest are controversial. Using data from the Parisian Region Out of hospital Cardiac ArresT prospective registry, we performed an analysis to assess the effect of an invasive strategy on hospital survival. METHODS AND RESULTS: Between January 2003 and December 2008, 714 patients with out-of-hospital cardiac arrest were referred to a tertiary center in Paris, France. In 435 patients with no obvious extracardiac cause of arrest, an immediate coronary angiogram was performed at admission followed, if indicated, by coronary angioplasty. At least 1 significant coronary artery lesion was found in 304 (70%) patients, in 128 (96%) of 134 patients with ST-segment elevation on the ECG performed after the return of spontaneous circulation, and in 176 (58%) of 301 patients without ST-segment elevation. The hospital survival rate was 40%. Multivariable analysis showed successful coronary angioplasty to be an independent predictive factor of survival, regardless of the postresuscitation ECG pattern (odds ratio, 2.06; 95% CI, 1.16 to 3.66). CONCLUSIONS: Successful immediate coronary angioplasty is associated with improved hospital survival in patients with or without ST-segment elevation. Therefore, our findings support the use of immediate coronary angiography in patients with out-of-hospital cardiac arrest with no obvious noncardiac cause of arrest regardless of the ECG pattern.